Amendments have been made to the procedure for monitoring the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance. Federal Compulsory Health Insurance Fund order and conditions for the provision of medical care

2. Launch Forms:

N ECO-TFOMS, starting from the report for January 2006;

N SV-TFOMS, starting from the report for the 1st quarter of 2006

3.With the introduction of the Forms specified in clause 1 of this Order, the MHIF Orders of March 15, 2001 No. 16 "On approval of forms of departmental and statistical observation" and of January 6, 2003 No. 3 "On approval of the form of departmental statistical observation N USN and amendments to the Order of the MHIF dated March 15, 2001 N 16 ", dated March 28, 2005 N 32" On approval of the form of departmental statistical observation N SV "Information on the receipt of funds for the compulsory medical insurance of the non-working population in the budget revenues of the TFOMS" ...

4. Executive directors of territorial funds of mandatory health insurance provide:

4.1. Representing Forms in Federal fund OMS in in electronic format and on paper in accordance with this Order.

4.2. Bringing this Order to the heads of structural divisions of territorial CHI funds.

5. The department of organization of income generation of CHI funds (A.F. Ptashuk) ensure current control over the submission of Forms according to the approved forms in deadlines.

6. The Control and Auditing Department (TS Markova), when carrying out inspections of the activities of territorial CHI funds, to exercise control over the fulfillment of the requirements of this Order.

7. The Information and Computing Center (AI Vorobiev) shall ensure the reception and processing of the Form data in electronic form, as well as the preparation of spreadsheets.

8. Control over the implementation of this Order shall be entrusted to the First Deputy Director Yu. Yakovleva.

Director
A.M. TARANOV

ORDER
FILLING IN THE FORM OF DEPARTMENTAL STATISTICAL SUPERVISION N ECO-TFOMS "MONTHLY REPORT ON RECEIPT OF TAX PAYMENTS AND INSURANCE CONTRIBUTIONS TO OMS INTO BUDGET TFOMS INCOME"

The initial data for filling out the form of departmental statistical observation N ECO-TFOMS "Monthly report on the receipt of tax payments and insurance premiums for compulsory health insurance in the budget revenues of TFOMS" (hereinafter - form N ECO-TFOMS) are bank statements transferred to the territorial funds of compulsory medical insurance under the corresponding codes classification of budget revenues of the Russian Federation. (as amended by the FFOMS Order of 28.12.2009 N 279)

Form N ECO-TFOMS data are compiled on an accrual basis from the beginning of the year in rubles with two decimal places after the decimal point. (as amended by the FFOMS Order of 28.12.2009 N 279)

Form N ECO-TFOMS is submitted by the territorial CHI funds in electronic form and on paper to the Federal CHI Fund on a monthly basis by the 5th day of the month following the reporting one. (as amended by FFOMS orders of March 16, 2009 N 48, of December 28, 2009 N 279)

Lines 01 - 09 indicate the amounts of funds received in the TFOMI budget revenues according to the corresponding codes for the classification of the budgets of the Russian Federation: (as amended by the FFOMS orders of 28.12.2009 N 279, of 04.03.2010 N 44)

page 01 - insurance premiums for compulsory health insurance credited to the territorial compulsory health insurance funds (as amended by the FFOMS Order of 28.12.2009 N 279)

p. 02 - unified social tax credited to territorial compulsory health insurance funds; (as amended by the FFOMS orders of 06.02.2008 N 24, of 28.12.2009 N 279)

p. 03 - single taxlevied in connection with the application of the simplified taxation system; (as amended by the FFOMS orders, dated 06.02.2008 N 24, dated 28.12.2009 N 279)

p. 04 - unified tax on imputed income for certain types of activities; (as amended by the FFOMS orders, dated 06.02.2008 N 24, dated 28.12.2009 N 279)

p. 05 - unified agricultural tax; (as amended by the FFOMS orders, dated 06.02.2008 N 24, dated 28.12.2009 N 279)

p. 06 - arrears, penalties and fines on contributions to the territorial compulsory health insurance funds; (as amended by the FFOMS orders, dated 06.02.2008 N 24, dated 28.12.2009 N 279)

p. 07 - funds from the budgets of the constituent entities of the Russian Federation transferred to the budgets of territorial compulsory health insurance funds for compulsory health insurance of the unemployed population; (as amended by the FFOMS orders of 06.02.2008 N 24, of 28.12.2009 N 279)

p. 08 - arrears and penalties on insurance premiums for compulsory health insurance of the non-working population; (as amended by the FFOMS orders of 06.02.2008 N 24, of 28.12.2009 N 279)

page 09 - monetary penalties (fines) imposed by the Pension Fund of the Russian Federation and its territorial bodies in accordance with Articles 48 - 51 of the Federal Law "On Insurance Contributions to the Pension Fund of the Russian Federation, Social Insurance Fund of the Russian Federation, Federal Mandatory Medical Insurance Fund and territorial compulsory health insurance funds. (as amended by the FFOMS Order of 04.03.2010 N 44)

(as amended by the FFOMS Order of 06.02.2008 N 24)

thousand rubles with one decimal place

Registered in the Ministry of Justice of Russia on January 28, 2011 N 19614
FEDERAL FUND OF MANDATORY HEALTH INSURANCE
ORDER

ORGANIZATION AND CONTROL OF VOLUMES, TERMS,

QUALITY AND CONDITIONS OF PROVIDING MEDICAL CARE

List of changing documents

In accordance with the Federal Law of November 29, 2010 N 326-FZ "On compulsory health insurance in the Russian Federation" I order:

1. To approve the attached Procedure for organizing and conducting control of volumes, terms, quality and conditions of provision medical care for compulsory health insurance (hereinafter - the Procedure).

2. The heads of territorial funds of compulsory medical insurance and medical insurance organizations shall use the attached Procedure when organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care for compulsory medical insurance.
The chairman

A. YURIN
ORDER

ORGANIZATION AND CONTROL OF VOLUMES, TIME, QUALITY

AND TERMS OF PROVIDING MEDICAL CARE

FOR MANDATORY HEALTH INSURANCE
List of changing documents

(as amended by the FFOMS orders of 16.08.2011 N 144,

from 21.07.2015 N 130, from 29.12.2015 N 277, from 22.02.2017 N 45)
I. General provisions
1. This Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance (hereinafter referred to as the Procedure) was developed in accordance with Chapter 9 of the Federal Law of November 29, 2010 N 326-FZ "On Compulsory Health Insurance in the Russian Federation "(Collected Legislation of the Russian Federation, 2010, N 49, Art. 6422; 2011, N 49 (Part I), Art. 7047; 2012, N 49, Art. 6758; 2013, N 27, Art. 3477 ; N 48, Art.6165) and defines the rules and procedure for organizing and conducting by insurance medical organizations and compulsory medical insurance funds of control over the volumes, terms, quality and conditions for the provision of medical care by medical organizations in the amount and on the conditions established by the territorial program of compulsory medical insurance and an agreement for the provision and payment of medical care for compulsory health insurance.

2. The purpose of this Procedure is to regulate measures aimed at exercising the rights of insured persons to receive free medical care in accordance with the territorial program of compulsory medical insurance and the agreement for the provision and payment of medical care for compulsory medical insurance in volumes, terms and conditions, of proper quality in medical organizations. participating in the implementation of compulsory health insurance programs.
II. Objectives of control of volumes, timing,

quality and conditions of medical care

for compulsory health insurance
3. The control of the volume, timing, quality and conditions for the provision of medical care under compulsory health insurance (hereinafter - control) includes measures to verify the compliance of the medical care provided to the insured person with the terms of the contract for the provision and payment of medical care under compulsory health insurance, implemented through medical economic control, medico-economic examination and examination of the quality of medical care.

4. The object of control is the organization and provision of medical care for compulsory health insurance. The subjects of control are territorial compulsory medical insurance funds, medical insurance organizations, medical organizations entitled to carry out medical activities and are included in the register of medical organizations operating in the field of compulsory medical insurance.

5. Objectives of control:

5.1. ensuring free provision of medical care to the insured person in the amount and under the conditions established by the territorial compulsory medical insurance program;

5.2. protection of the rights of the insured person to receive free medical care in the amount and under the conditions established by the territorial compulsory health insurance program, of appropriate quality in medical organizations participating in the implementation of compulsory health insurance programs, in accordance with contracts for the provision and payment of medical care for compulsory health insurance ;

5.3. prevention of medical care defects resulting from the inadequacy of the medical care provided to the health status of the insured person; non-compliance and / or incorrect implementation of the procedures for the provision of medical care and / or standards of medical care, clinical recommendations (treatment protocols) on the provision of medical care, medical technologies by analyzing the most common violations based on the results of control and taking measures by the authorized bodies;

(as amended by the FFOMS Order dated July 21, 2015 N 130)

5.4. verification of the fulfillment by insurance medical organizations and medical organizations of obligations to pay and provide free medical care to insured persons under compulsory medical insurance programs;

5.5. checking the fulfillment by medical insurance organizations of obligations to study the satisfaction of insured persons with the volume, availability and quality of medical care;

5.6. optimization of the cost of paying for medical care when insured event and reduction of insurance risks in compulsory health insurance.

6. Control is carried out by means of medical and economic control, medical and economic examination, examination of the quality of medical care.
III. Medical and economic control
7. Medical and economic control in accordance with part 3 of article 40 of the Federal Law of November 29, 2010 N 326-FZ "On compulsory health insurance in the Russian Federation" (hereinafter - the Federal Law) - establishing the compliance of information on the volume of medical care provided to insured persons on the basis of the registers of invoices submitted for payment by the medical organization to the terms of contracts for the provision and payment of medical care under compulsory medical insurance, the territorial compulsory medical insurance program, methods of payment for medical care and tariffs for payment of medical care.

8. Medical and economic control is carried out by specialists of medical insurance organizations and territorial compulsory medical insurance funds.

9. During medical and economic control, all cases of medical care are monitored under compulsory health insurance in order to:

1) checking account registers for compliance with the established procedure for information exchange in the field of compulsory health insurance;

2) identification of the person insured by a specific medical insurance organization (payer);

3) checking the compliance of the provided medical care:

a) the territorial compulsory health insurance program;

b) the terms of the contract for the provision and payment of medical care for compulsory health insurance;

c) a valid license of a medical organization to carry out medical activities;

4) checking the validity of the application of tariffs for medical services, calculating their cost in accordance with the methodology for calculating tariffs for payment for medical care approved by the authorized federal executive body, methods of payment for medical care and tariffs for payment for medical care and an agreement for the provision and payment of medical care for compulsory health insurance;

5) establishing that the medical organization does not exceed the volume of medical care established by the decision of the commission for the development of territorial program compulsory health insurance, payable from compulsory health insurance funds.

10. The violations identified in the account registers are reflected in the act of medical and economic control (Appendix 1 to this Procedure) with an indication of the amount of account reduction for each register entry containing information about medical care defects and / or violations in the provision of medical care.

In accordance with Parts 9 and 10 of Article 40 of the Federal Law, the results of medical and economic control, drawn up by the relevant act in the form established by the Federal Fund for Compulsory Medical Insurance, are the basis for the application of measures provided for in Article 41 of the Federal Law, the terms of the contract for the provision and payment of medical care on compulsory medical insurance and a list of grounds for refusing to pay for medical care (reducing the payment for medical care) (Appendix 8 to this Procedure), and may also be the basis for a medical and economic examination; organization and examination of the quality of medical care; carrying out repeated medical and economic control, repeated medical and economic examination and examination of the quality of medical care territorial fund compulsory health insurance or an insurance medical organization on the instructions of the territorial fund

IV. Medical and economic expertise
11. Medical and economic examination in accordance with Part 4 of Article 40 of the Federal Law - establishing the correspondence between the actual terms of medical care, the amount presented for payment medical services records in primary medical records and accounting and reporting documents of a medical organization.

12. Medical and economic examination is carried out by a specialist expert (paragraph 78 of Section XIII of this Procedure).

13. Medical and economic expertise is carried out in the form of:

a) targeted medico-economic expertise;

b) planned medical and economic examination.

14. Targeted medical and economic examination is carried out in the following cases:

a) repeated visits for the same disease: within 15 days - in the provision of outpatient care, within 30 days - in case of repeated hospitalization; within 24 hours from the moment of the previous call - upon a repeated call for an ambulance;

(subparagraph "a" as amended by the FFOMS Order of 22.02.2017 N 45)

b) has lost its force. - Order of FFOMS dated 02.22.2017 N 45;

c) receiving complaints from the insured person or his representative about the availability of medical care in a medical organization.

A targeted medical and economic examination is carried out within a month after the submission of registers of accounts and invoices for payment of medical care for medical care provided to insured persons, with the exception of cases stipulated by the legislation of the Russian Federation.

When conducting a targeted medical and economic examination in cases of re-admission (hospitalization) for the same disease, the established terms are calculated from the moment the invoice is submitted for payment containing information on re-admission (hospitalization).

(the paragraph was introduced by the FFOMS Order of July 21, 2015 N 130)

Conducting targeted medical and economic expertise in the event of complaints from insured persons or their representatives does not depend on the time that has passed since the provision of medical care.

(the paragraph was introduced by the FFOMS Order of July 21, 2015 N 130)

The number of targeted medical and economic examinations is determined by the number of cases requiring it to be carried out on the grounds specified in this Procedure.

(the paragraph was introduced by FFOMS Order of December 29, 2015 N 277)

15. Planned medical and economic examination is carried out within a month on the accounts provided for payment for the medical care provided to the insured person under compulsory medical insurance.

(as amended by FFOMS orders of 21.07.2015 N 130, of 29.12.2015 N 277)

16. When carrying out a planned medical and economic examination, the following are assessed:

a) the nature, frequency and causes of violations of the rights of insured persons to receive medical care under compulsory health insurance in the amount, terms, quality and conditions established by the contract for the provision and payment of medical care under compulsory health insurance;

b) the amount of medical care provided by the medical organization and its compliance with the amount established by the decision of the commission for the development of the territorial compulsory medical insurance program to be paid from the funds of compulsory medical insurance;

c) the frequency and nature of violations by a medical organization of the procedure for forming account registers.

17. The volume of monthly medical and economic examinations of the number of completed treatment cases is at least:

(as amended by the FFOMS Order of 22.02.2017 N 45)

in the provision of inpatient medical care - 8%;

when providing medical care in day hospital - 8%.

When providing medical care on an outpatient basis - 0.8% of the number of insured events submitted for payment.

(as amended by the FFOMS Order of December 29, 2015 N 277)

When providing medical care outside a medical organization - 3% of the number of cases submitted for payment.

If, within a month, the number of defects in medical care and / or violations in the provision of medical care exceeds 30 percent of the number of cases of medical care for which a medical and economic examination was carried out, in next month the volume of checks from the number of bills accepted for payment in cases of medical care must be increased at least 2 times compared to the previous month.

(Clause 17 as amended by the FFOMS Order of 21.07.2015 N 130)

18. With regard to a certain set of cases of medical care, selected according to thematic criteria (for example, the frequency and types of postoperative complications, duration of treatment, cost of medical services) in a medical organization in accordance with the plan agreed upon by the territorial compulsory health insurance fund, a planned thematic medical and economic examination, for which the selection of cases is carried out within one year from the date of submission of invoices and registries of invoices for payment.

(as amended by the FFOMS Order dated July 21, 2015 N 130)

19.According to the results of a planned or targeted medical and economic examination, a specialist expert draws up an act of medical and economic examination in two copies: one is sent to medical organization, one copy remains in the medical insurance organization / territorial fund of compulsory health insurance.

(as amended by the FFOMS Order of 22.02.2017 N 45)

In the absence of defects in medical care / violations in the provision of medical care (in accordance with the list of grounds for refusing to pay for medical care (reducing the payment for medical care), an act of medical and economic examination is drawn up in accordance with Appendix 10 to this Procedure.

(as amended by the FFOMS Order of 22.02.2017 N 45)

In case of revealing defects in medical care / violations in the provision of medical care (in accordance with the list of grounds for refusing to pay for medical care (reducing the payment for medical care), an act of medical and economic examination is drawn up in accordance with Appendix 3 to this Procedure.

Application. Changes to the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance, approved by order of the Federal Compulsory Health Insurance Fund No. 230 of December 1, 2010

Order of the Federal Compulsory Medical Insurance Fund of July 21, 2015 N 130
"On amendments to the Procedure for organizing and monitoring the volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance, approved by order of the Federal Compulsory Medical Insurance Fund No. 230 of December 1, 2010"

In accordance with chapter 9 Federal Law of November 29, 2010 N 326-FZ "On Compulsory Medical Insurance in the Russian Federation" (Collected Legislation of the Russian Federation, 2010, N 49, Art. 6422; 2011, N 49, Art. 7047; 2012, N 49, Art. 6758; 2013, N 27, Art. 3477; N 48, Art. 6165) and in order to improve the organization and control of volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance, I order:

Make changes to Order organization and control of volumes, terms, quality and conditions for the provision of medical care for compulsory health insurance, approved by order Federal Compulsory Medical Insurance Fund of December 1, 2010 N 230 (registered with the Ministry of Justice of the Russian Federation of January 28, 2011, registration N 19614) as amended by order of the Federal Compulsory Medical Insurance Fund of August 16, 2011 N 144) (registered with the Ministry of Justice of the Russian Federation on December 9, 2011, registration N 22523) according to application to this order.

Registration N 38182

Amendments have been made to the procedure for monitoring the volume, timing, quality and conditions for the provision of medical care under compulsory medical insurance.

A number of changes are due to the clarification of the timing of medical examinations. Thus, the monthly period for conducting a targeted medical and economic examination is calculated after the submission of registers of accounts and bills for payment of medical care.

The volumes of monthly medical and economic examinations, as well as examinations of the quality of medical care, were determined from the number of completed cases of treatment when providing medical care outside the medical organization.

The concept of "examination of the quality of medical care" has been clarified.

Cases of extending the terms of the targeted expertise of the quality of medical care have been identified. A one-month deadline has been set for organizational expert measures (for example, requesting materials for the examination and their analysis).

Defects and (or) violations in the provision of medical care are described for the application of penalties against a medical organization. Among them, violation of the conditions for the provision of medical care, harm to the health of insured persons, violation of medical ethics and deontology by medical workers, failure to comply with diagnostic and (or) treatment measures for the patient.

The forms of documents drawn up based on the results of control activities have been adjusted.

Order of the Federal Compulsory Medical Insurance Fund of July 21, 2015 N 130 "On Amendments to the Procedure for Organizing and Controlling the Volume, Timing, Quality and Conditions of Provision of Medical Care for Compulsory Health Insurance, approved by order of the Federal Compulsory Medical Insurance Fund of December 1, 2010 g. N 230 "

Registration N 38182

This order comes into force after 10 days after the day of its official publication

By order FFOMS dated February 28, 2019 N 36, this document was declared invalid from June 29, 2019.